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<h1 class="p_Heading1"><span class="f_Heading1">Custom Reports Field Groups - AIDSRelief Form Fields</span></h1>

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<p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 10pt; font-family: Arial;">Updated July 27, 2009</span></p>
<div style="text-align: center; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 0px;"><table style="margin:0 auto; width:886px; border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:23px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Field Groups:</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:23px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Care Ended</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:23px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Clinical Status</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:23px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Custom Fields</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:23px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Employee</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:23px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Facility Information</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">DB View Name:</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt_PatientCareEnded</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientClinicalStatus</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _CustomField_Results</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _Employee</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _Facility</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Data Fields:</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">ART Ended</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Clinical Signature</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Custom Field Label</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Employee Designation</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">App Grace Period</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">ART Ended Date</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Date HIV Diagnosis</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Custom Field Result</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Employee First Name</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Country Num</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">ART Ended Reason</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Disclosure</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Employee Last Name</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Currency</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Care Ended</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Disclosure Relationship</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;"> (All of the custom fields created </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Employee Name</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Facility Name</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Care Ended Date</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">HIV Diagnosis Verified</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;"> by the site will be in the field </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">LPTF Num</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Care Ended Signature</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">LMP</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;"> select list)</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">PEPFAR Start Date</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Death Date</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Pregnant</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Satellite Num</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Death Reason</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Death Reason Description</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">LPTF Transferred To</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Stopped Reason</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Stopped Reason Other</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Exit Reason</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:105px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:127px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:153px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:141px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:125px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
<div style="text-align: center; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 0px;"><table style="margin:0 auto; width:868px; border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:86px; height:32px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Field Groups:</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:32px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Family Information</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:32px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">HIV Information</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:32px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">HIV Previous Care</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:32px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Laboratory</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:32px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">OIs or AIDS Defining Illnesses</span></p>
</td>
<td style="vertical-align:top; padding:4px; border:solid 1px #000000;"><br />
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">DB View Name:</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt_Family Information</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientHIVOther</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientHIVPreviousCare</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _Laboratory</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _OISorAIDSDefingIllnesses</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Data Fields:</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Family Member Name</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Enrollment Support Group</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Ever Been on ART</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">AIDSRelief Financed Lab</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Date Of Disease</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">HIV Care Status</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">HIV Barrier</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ART Sponsor</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Checked by Date</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Defining Illness</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">HIV Status</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">HIV Disclosure</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ART Sponsor Other</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Checked by Name</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Defining Illness Description</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Registered</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">HIV Disclosure Other</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous Care Type</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lab Department</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Relationship</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">HIV Status</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous Care Type Other</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lab Ordered by</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Relationship date</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Num Household HIV Died</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous HIV Care</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lab Ordered by Date</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Relative Age (Month)</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Num Household HIV Positive</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous Medical Records</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lab Test</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Relative Age (Year)</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Num Household HIV Tested</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lab Unit</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Relative Sex</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Referred From Inpatient Ward</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Max Boundary Value</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Referred From </span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Min Boundary Value</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Support Group Name</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Pre Clinic Lab Date</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Reported by </span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Reported by Date</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Test Results (text or numeric)</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:middle; width:87px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:111px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:138px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="margin: 0px 0px 0px 3px;"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:140px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:middle; width:143px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<div style="text-align: center; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 0px;"><table style="margin:0 auto; width:888px; border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Field Groups:</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Patient Adherence</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Patient Appointment</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Patient Assessment and Therapy</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Patient Contacts</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:29px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">DB View Name:</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:29px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientAdherence</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:29px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientAppointment</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:29px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientAssessment</span></p>
<p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientTherapy</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:29px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientContacts</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Data Fields</span><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">:</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Adherence Code</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Appointment Date</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">AIDSRelief ARV Start Date</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Emergency Contact Address</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Adherence Other Details</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Appointment Provider</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Assessment Category</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Emergency Contact Discuss Status</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Adherence Support Group</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Appointment Purpose</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Assessment Description - IE</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Emergency Contact Knows HIV Status</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Herbal Meds</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Appointment Status</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Assessment Name</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Emergency Contact Name</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Interrupted Date</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Therapy Plan</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Emergency Contact Phone</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Interrupted Num Days</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Therapy Reason Code</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Emergency Contact Relationship</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Missed Last Week</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Missed Last Month</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Num DOT Per Week</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Num Home Visits Per Week</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Stopped Date</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Stopped Num Days</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:178px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<div style="text-align: center; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 0px;"><table style="margin:0 auto; width:939px; border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Field Groups:</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Patient Demographics</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Patient Symptoms</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Pharmacy</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Previous Regimen</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">DB View Name:</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientDemographics</span></p>
</td>
<td style="vertical-align:bottom; width:191px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientSymptoms</span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PharmacyDispense</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientHivPrevCareIE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Data Fields</span><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">:</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Age</span></p>
</td>
<td style="vertical-align:bottom; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Symptom Category</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">AIDSRelief Financed Drug</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Allergy Name</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Age at Enrollment</span></p>
</td>
<td style="vertical-align:bottom; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Symptom Description</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Dispensed By</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Allergy Other Details</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">AIDSRelief ART Start Date</span></p>
</td>
<td style="vertical-align:bottom; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Symptom Name</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Dispensed By Date</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">CD4 % Prior to ARVs</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Current ART Regimen</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Dispensed Quantity</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">CD4 Prior to ARVs</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Current ART Regimen Start Date</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Dose</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">CD4 Prior to ARVs Date</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Date of Birth</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Drug Abbreviation</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Current ART - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Distance Travelled (Km)</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Drug Name</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Current ART Start Date - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">District</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Drug Type</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term Meds Other - 1</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Education Level</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Duration</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term Meds Other Desc - 1</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Employment Status</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Frequency</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term Meds Other Desc - 2</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Enrollment Date</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Generic Drug Name</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term Meds Other Desc - 3</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Existing Hosp/Clinic #</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Hold Medicine</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term Meds Sulfa</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Literacy</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Order Type {text translation}</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term Meds Sulfa Desc</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Local Council</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Ordered Quantity</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term TB Med Desc</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Marital Status</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Pharmacy Ordered By</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term TB Medication</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Monthly Income</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Pharmacy Ordered By Date</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Long Term TB Start Date</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Num Children</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Regimen</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lowest CD4 - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Num People In Household</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Treatment Program</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lowest CD4 Date - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Occupation</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">ARV Provider</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Lowest CD4 Percent - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Address</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Regimen Code</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Most Recent CD4 - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Enrollment #</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">OI Treatment</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Most Recent CD4 Date - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient First Name</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Most Recent CD4 Percent - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Last Name</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Most Recent Viral Load Date - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Location</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Most Recent Viral Load - IE</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Name</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Phone</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen Months</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Patient Status</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen1 Current</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Province</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen1 Months</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Sex</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen1 Name</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Status Changed Date</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Time Travelled</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Travel Units</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Village</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:103px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:191px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:202px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:181px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 0px;"><table style="width:878px; border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:107px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Field Groups:</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Previous Regimen (continued)</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Therapy and Adherence</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Visit</span></p>
</td>
<td style="vertical-align:middle; width:142px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Vital Signs</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; background-color:#e0e0e0; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1" style="text-align: center;"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">WAB &amp; WHO Stage</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:107px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">DB View Name:</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientHivPrevCareIE</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _AdherenceMissedReason</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _Visit</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientVitals</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; background-color:#ccffff; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-style: italic;">Rpt _PatientStage</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:middle; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial; font-weight: bold;">Data Fields</span><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">:</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen2 Current</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Reason Category</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Treatment Location</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">BP Diastolic</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">WAB Stage</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen2 Months</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Reason Code</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Visit Type</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">BP Systolic</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">WHO Stage</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen2 Name</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Visit Date</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Heart Rate</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen3 Current</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Height (cm)</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen3 Months</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Pain</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen3 Name</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Respiratory Rate</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen4 Current</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Temp (°C)</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen4 Months</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Weight (kg)</span></p>
</td>
<td style="vertical-align:bottom; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Previous ARV Regimen4 Name</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;"> </span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Single Dose NVP</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Single Dose NVP Date-1</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1" style="font-size: 8pt; font-family: Arial;">Single Dose NVP Date-2</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:166px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:middle; width:106px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:bottom; width:142px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:107px; height:17px; padding:4px; border:solid 1px #000000;"><p class="p_Normal-1"><span class="f_Normal-1">&nbsp;</span></p>
</td>
</tr>
</table>
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